[Online consultation] Topic 2: Key affected women and girls

The Asia Pacific Alliance for Sexual and Reproductive Rights (APA), Citizen News Service (CNS) and SEA-AIDS eForum Resource Team have launched the topic 2 of online consultation in lead up to the 10th International Congress on AIDS in Asia and the Pacific (10th ICAAP). The Topic 2 is open for comments during 1-20 August 2011. GUIDING QUESTION is: What strategies would you priorities to address the needs and rights of key affected women and girls? In your response, please clarify who you consider key affected women and girls and what are the main challenges in ensuring a more enabling environment for these women and girls? Please share examples. Have your say! (send comments to bobby@citizen-news.org)
BACKGROUND NOTE: Most countries in the Asia Pacific region are experiencing concentrated epidemics, with men who have sex with men (MSM), sex workers (SW) and their clients, and people using drugs (PUD) identified as the key affected populations (KAPs). Programmes for KAPs should be designed to include women and girls such as female drug users, female and transgender sex workers and wives of married MSM. For example, women and girls have specific sexual and reproductive health needs that are often not sufficiently addressed in HIV and AIDS programmes.

Furthermore, key affected women and girls lack opportunity and support to have their voices heard. In order to ensure more attention to women and girls at ICAAP and beyond, we would like to offer this opportunity to hear from you in this online consultation.

24 comments:

HIV-specific needs of women and girls are addressed in at least half of all national HIV responses: The challenge in the developing countries to address this issue is of service providers of the same sex. The Global Fund should get commitment from the countries/ states for the same particularly in socio-culturally restricted societies.

Zero tolerance for gender-based violence. An ideal and excellent statement of Intention! The Global Fund needs to articulate this better to facilitate countries in translating into actions.

I would to introduce myself before the Forum. My name is Florencia FarEDas Franzosi and I belong to ISO at ICW Global. On behalf of the network, I would like to share these thoughts about Human Rights.

In many countries, the stigma and discrimination suffered by women, young women, girls and adolescents living with HIV/AIDS have consequences of big scope from the loss of job position and properties, lack of access to food and/ or education, the abandon of family or friends, violence against her life or in danger. All these conditions, related to different areas of the human nature, should be taken into consideration in the programs. So, that they comply with the real needs of its population.

Thus, to ensure universal access to prevention it is essential that an approach from the perspective of human rights and gender into these programs to ensure effective and fully the rights of women, youth and adolescents living with HIV/AIDS.

We should consider increasing support for harm reduction services for male and female injecting drug users (IDUs) and female partners of male IDUs along with working with the government of countries where conflicting policies exist.

In many countries drug is criminalised and there is a clear need to protect public health policies from such demonising laws because it is neither in interest of social justice nor public health.

Harmonising policies on harm reduction and de-criminalising drug use is high priority in communities where injecting drug use has been proven to be a driver of HIV epidemic.

It is a human rights issue to provide reproductive health services for female injecting drug users (IDUs) - the stigma in general healthcare services is alarmingly high - and a friendly, safe and supportive healthcare service facility for female IDU is a rare find.

The document online at: http://www.scribd.com/doc/61507388/Action-Plan-Final-June11-ICRW is from a research study that we conducted among sex workers in Pune and wives of migrant men in Orissa, under the aegis of the universal access to HIV services for women and girls. The document relates to our recommendations and suggested action plan to improve services for these two populations. The recommendations follow our key findings, and are addressed to both the public and private sector.

Hope you find it useful.

Enisha Sarin, ConsultantInternational Centre for Research on Women (ICRW)Email: esarin-consultant@icrw.org

Gender-sensitive harm reduction approaches for female IDUs and female partners of IDUs is seriously lacking in harm reduction services that exist today. Of course we need to sale up harm reduction services but also make them gender sensitive to needs of female IDUs and female partners of IDUs.

I commend The Asia Pacific Alliance for Sexual and Reproductive Rights (APA), Citizen News Service (CNS) and SEA-AIDS eForum in launching the online consultation leading to ICAAP 10 and particularly raising the question addressing the needs and rights of key affected women and girls.

"Nothing About US Without US", it is imperative that affected women and girls be involved at each and every process in policy making, designing and delivery of national programmes. These include young girls and women living with HIV, female sex workers, wives/partners of drug users, female drug users, transgenders and also wives married to MSM.

The International Conference on Population and Development (ICPD) in Cairo in 1994, established the concept of comprehensive sexual and reproductive health and rights (SRHR). There is an urgent need to reaffirm the linkages and synergies between HIV and SRH, and their inter-relationships within broader issues of public health, development and human rights.

It is imperative to emphasize that the overwhelming majority of HIV infections are sexually transmitted or associated with pregnancy, childbirth and breastfeeding. Both HIV, and sexual and reproductive ill-health, are driven by many common root causes, including gender inequality, poverty and social marginalization of the most vulnerable populations.

Addressing the needs of young girls and women, is critical to the achievement of every one of the Millennium Development Goals (MDGs).

Three of the UN endorsed MDGs are directly pertinent to the reproductive health of women and young girls living with HIV. MDG 3 seeks to achieve greater gender equality and empower women; MDG 5 aims to improve maternal health; and MDG 6 focuses on stopping and reversing the spread of HIV infection.

Stronger linkages between HIV and SRH services will result in more relevant and cost-effective programmes with greater impact.

There should be a comprehensive strategy to address the needs for Females who use/Inject drugs in the region. There are hardly any separate interventions or DICs and programs for such vulnerable community under harm reduction, specifically in areas where such community exists. We always talk about gender balance but when it comes to female there is nothing much to see or hear.

Even in the existing national or regional networks, female participation is almost nil. So what can we do, to amplify their voices in the region and bring them on board? There are so many other critical issues to address, pertaining to females, who use/inject drugs. Are we really taking any steps to address those issues? or we are still saying that it is a hidden population and therefore, difficult to address?

Let's do some desk review and home work on this and learn something from the International strategies.

APPARENTLY FROM THAT, THE HIV/HEP B & C VULNERABLITIY ARE ALSO NOT ADDRESSED.

Programmes made to reach out to female partners of IDUs, or female IDUs, need to be very sensitive gender-wise and also on issues around IDU and harm reduction. Gender-sensitive reproductive health programmes for example are not able to meet reproductive health needs of female IDUs. So we need more sensitisation and friendly service environment to increase uptake of existing services.

APA Secretariat would like to share that a case study on HIV prevention program in India with most-at-risk populations, including sex workers, by APA member Pathfinder International, has been published by Harvard Business Publishing and Harvard University’s Global Health Delivery Project. Pathfinder’s “Mukta” project in Maharashtra, India demonstrates HIV prevention taking a community and health system strengthening approach, funded by the Bill and Melinda Gates Foundation’s Avahan India AIDS Initiative. More information can be accessed here: http://www.pathfind.org/site/PageServer?pagename=News_Harvard_Business_School_Publishes_Pathfinder_Case_Study

If we want to end HIV in the region which key affected women do we need to reach? SEX WORKERS! Focusing HIV prevention on sex work is the most cost-effective investment in Asia and the Pacific.

In October 2010 the first ever Regional Consultation on HIV and Sex Work took place in Pattaya Thailand. Over 140 participants from the region - over one third of them sex workers or representatives of sex worker organisations and networks and the majority of them women and transgender came together and discussed about the best strategies forward in the areas of: sexual and reproductive health and rights of sex workers; creating an enabling legal and policy environment; eliminating violence against sex workers; and migration and mobility in the context of HIV and sex work. Participation of sex workers and addressing stigma and discrimination served as cross-cutting themes.

Some of the main recommendations developed by sex workers UN and government officials at the Pattaya Consultation include:

- Meaningful participation of sex workers - "Nothing about us without us" Include sex workers as partners in development and implementation

- Support self-organizing by sex workers

- Stigma and discrimination: Involve influential people in society and leverage their influence to tackle stigma and discrimination related to sex work and HIV

- Creating an enabling legal and policy environment

- Insist on universal rights for sex workers

- Remove criminal laws against sex workers (which is essential but not sufficient)

- Ensure access to justice for sex workers

- Accept that sex work is work

- Sexual and reproductive health (SRH) and rights: Ensure condom programmes address all aspects of supply demand and environment within a rights based approach

- Provide a comprehensive set of sexual and reproductive health and HIV services to sex workers that address the whole spectrum of prevention treatment care and support from a rights-based approach

- Eliminating violence against sex workers: Human rights institutions need to keep up violence against sex workers including by state actors as human rights violations. Address violence and violence prevention in all HIV programmes targeting sex workers and their clients. Provide safe working spaces for sex workers

- Addressing migration and mobility in the context of HIV and sex work: Ensure anti-trafficking laws do not impede the human rights of sex workers

- Provide anonymous health and social services for migrants including migrant sex workers

Full the full report go to: http://asiapacific.unfpa.org/webdav/site/asiapacific/shared/Publications/2011/Building%20Partnerships%20on%20HIV%20and%20Sex%20Work%202.pdf

The drop-in centres and other AIDS-related healthcare service centres are providing counselling for HIV to transgender people, but counselling for mental health issues is not being looked upon adequately.

Many transgender people in Tamil Nadu are school drop-outs. Many transgender activists who went for sex reassignment surgeries in Tamil Nadu broke down, cried, due to the trauma and insult they had to face while going through the psychiatric counselling process.

There is no denying to the fact that mental health issues are unique to transgender people, and are not adequately being addressed. Mental health needs are huge for transgender as they are neglected and maltreated by the society, and their own family friends or family in some cases who are source of trauma.

Earlier experience of trauma comes from your own family and friends. Maltreatment includes teasing, humiliation coming from very closed ones, not even given the minimum respect or importance of what you expect from your family members.

Mental health issues of Transgender populations particularly sex workers need attention. I am reminded of my experience and learning at the 2010 State Consultation for Transgender populations in West Bengal.

Depression, harassment, relationship problems, loneliness, and social isolation, were among the few pressing mental health concerns that were identified in a skill building workshop for transgender community.

"We are referred to our friends or community people. We rarely go to official psychologist or psychiatrist" was the response from the transgender communities (Source: CNS). HIV and STI counselling is more concerned with sexual and reproductive health, and doesn't adequately address mental health concerns beyond HIV prevention and to some extent care and support issues. There were strong remarks made on the inadequate counselling on HIV treatment, care and support.

"When there is adequate self-esteem and self-respect, there is a natural desire to be healthy, to take care of one self, to engage in safer sexual practice. So none of what we do will be successful if we ignore mental health issues" had said Aniruddh Vasudevan (Source: CNS).

Another significant comment Aniruddh made at this 2010 consultation was that the members of affected communities need capacity building and must be competent enough to contribute effectively in programmes addressing their community. "Just coming from a community doesn't mean that the person is automatically equipped to peer counsel – we have to do something to equip ourselves" said Aniruddh. "Peer counselling is not about offering solution – because the message that gets across is the person being counselled is not capable enough of finding solutions" had shared Aniruddh Vasudevan.

Thought sharing these learning from the 2010 state consultation for transgender populations might help.

The funds from the Global Fund to fight AIDS, Tuberculosis and Malaria (The Global Fund) are being used in numerous countries in Asia (and probably other regions as well) for programmes that violate basic human rights and accepted universal ethical standards in health care.

The funding of compulsory detention centres for drug users and sex workers is one example.

The other things we see over and over in sex work programming is compulsory or highly coercive testing- for STIs and HIV.

Compulsory testing of sex works is not only driven by government policies which ignore human rights- but is also being driven by GF indicators which give programmes ridiculous targets of the number of sex workers (or MSM or IDUs) who must be tested in order to meet M and E targets.

This not only violates the rights of sex workers and others, but in many cases it wastes huge amounts of money doing repeat tests for people who really don't need testing.

These results are then not kept confidential- they are, in many cases, shared with sex business owners and needlessly shared among staff of implementing organisations.

In many cases sex workers were better off before the Global Fund came in and scaled up the abuses of their rights and gave governments and NGOs money to further control their lives.

KEY AFFECTED WOMEN AND GIRLSAs such, girls and women are always vulnerable to sex and violence because of gender based inequalities. However, besides female sex workers and drug users other key affected women are as follows:

1. Women left alone at home in the villages for long due to service outside or migration of labourers2. Migrant women labourers in the towns and cities3. Girls and women who stay in working hostels or other hostels away from home or not under direct supervision of parents

STEPS TO BE TAKEN1. Listing of migrant women in cities and their monitoring2. Supervision and strict schedule of working hostels/hostels3. Increase awareness among them about safe sex, HIV/AIDS etc

What strategies would you priorities to address the needs and rights of key affected women and girls? In your response, please clarify who you consider key affected women and girls and what are the main challenges in ensuring a more enabling environment for these women and girls?

I have interviewed several women positively living with HIV from different regions of India. But their experiences are so similar. All of them lamented that they had contracted the disease from their husbands after marriage, and then thrown out of their in-laws house. Their biggest problem, apart from social stigma, is how to fend for themselves and their children. They find it almost impossible to fight court cases to get a share in the family property, despite the law being on their side. If they are given free legal aid and helped to get what is rightfully theirs, it will at least solve their financial problems, which will go a long way in helping them lead a dignified life.

At the recent 28th PCB meeting, a background paper on gender-sensitivity of AIDS response, The UNAIDS Agenda for Women and Girls, calls for appropriate systems to be established to investigate and document violence and the link between HIV and different forms of violence against all women and girls, including key affected populations such as sex workers, women living with HIV, women who use drugs, young women and transgender women.

Stigma, discrimination and the criminalisation of key affected populations, including sex workers and women who use drugs, prevent women from reporting acts of violence against them and seeking assistance and redress. Furthermore, there is growing concern that anti-trafficking laws and policies put in place to protect people from violence and exploitation are being used by law enforcers to arrest sex workers or demolish sex work establishments, thereby increasing vulnerability (refer to UNAIDS/PCB (28)/11.5)

There remains a scarcity of financial support to substantively develop the leadership of women, particularly networks of women living with HIV and women in key affected populations and enabling them to take a leading role in efforts to change the HIV trajectory is key to reversing the HIVepidemic.

The UNAIDS Agenda for Women and Girls calls for women and girls, especially those living with HIV, key affected young women and transwomen, female sex workers and female drug users to be engaged in making decisions on developing, designing, implementing, monitoring and evaluating HIV policies and programmes. What they bring is the capacity and experience of how the HIV response can best meet their HIV and sexual and reproductive health needs and rights.

Our hope as delegates for the region is that a guidance note be developed to support UNAIDS recently developed investment framework so that gender-based violence and support for building leadership in communities particularly women living with HIV and key affected women, be developed in order to better arm community representatives on Country Coordinating Mechanism's at the national level.

A new report indicates that most major bilateral, multilateral and private philanthropic funders that focus on HIV do not consistently track their investments targeting men who have sex with men (MSM) and transgender people. Produced by the Global Forum on MSM & HIV (MSMGF), the report also examines tracking of domestic government funding dedicated to these populations in all UN Member States, revealing that only 25% these countries recorded levels of HIV prevention spending for MSM in 2010 and no country tracked spending for transgender people.

"With overwhelming evidence for the need to prioritize MSM and transgender people in the global fight against AIDS, it is shocking that so few funders actually know how much money they are spending on these populations," said Dr George Ayala, Executive Officer of the MSMGF. "Funders often talk about the importance of investing in key affected populations, but budgets offer a clear reflection of what their priorities actually are. HIV investments must be accounted for in order to ensure that MSM and transgender people are getting the support they need."

"After 30 years of diffused investment, the world is realizing that a focused approach is the only one that will work," said Dr. Ayala. "It is time for funders to reflect that in their budgets and track their investments by population. Donor agencies must communicate and coordinate to ensure adequate coverage without duplication, and we must all aim for a higher level of accountability to the people we serve."

The full report, "An analysis of major HIV donor investments targeting men who have sex with men and transgender people in low- and middle-income countries," can be accessed online at: http://www.msmgf.org/files/msmgf//Publications/Global_Financing_Analysis.pdf

Dr Sadhu Charan Panda, I note that while you set aside talking about female sex workers and drug users when you present your list of key affected women and girls, I do hope you meant to include transgender women, hijras or other gender-variant women. If we do not include them here, they will be left out of the HIV interventions altogether because they do not belong, as they say, to the category of MSM, yet their risk for HIV and other ills is of the highest of most key affected populations.

To Shobha Shukla, excellent point and so glad to see you make it as I have not seen it yet in this discussion (although I apologize if it has appeared; I like many of us are very stressed this week preparing for the 10th ICAAP in Busan). Access to basic legal services is essential to helping PLHIV women and their families obtain what the law provides for them (in most countries) and what society denies them: property ownership, employment opportunities and social protection coverage for basics like health care, food, water and shelter. India certainly leads the region in human rights guarantees and creating access to legal services will help those rights to be finally realized.

If there are sensitive lawyers who can help community-based networks of transgender populations, transgender/ female sex workers, female injecting drug users, and other key affected women and girls as identified by SEA-AIDS members, to get them their due: property rights, right to healthcare, right to employment, right to basic amenities - this will be a huge help. Not only this will save time (and reduce time of agony affected communities go through) but it will also save lot of money and pain.

We have a prevention technology available today that could go a long way in helping women obtain protection from HIV infection: the female condom. It is designed specifically for women to initiate and use, and it offers protection from HIV, other STIs, and pregnancy.

Unfortunately, female condoms are not making it into the hands of most women, be they married women, migrant women, sex workers, rural women, or adolescents. Young, sexually active women in Asia could benefit in particular from dual protection methods like the female condom. According to the Guttmacher Institute (2011), 72 percent and 37 percent of women younger than 20 have an unmet need for modern contraceptives in South Central Asia and Southeast Asia, respectively (online at: http://www.guttmacher.org/pubs/Contraceptive-Technologies.pdf ).

It's a shame that such a valuable technology that exists today is so underutilized. Structural reasons have a lot to do with this, such as limited government and donor support for the purchase, distribution, and programming of female condoms.

As advocates, we should urge decision makers to endorse policies and funding that raise awareness of and access to more protection options for women.

This also includes building the knowledge and skills of women so that they can use these technologies effectively.

While we must most-certainly address specific and unique social determinants that continue to heighten HIV risk for transgender populations, female sex workers, female partners of men who have sex with men (MSM) and other key affected women and girls, we should also push for more women initiated prevention options such as existing (but hardly available!) female condoms and other options in clinical research pipeline such as microbicides or vaccines.

We must ensure that adequate investment is mobilized and sustained, and research, development and eventual introduction of safe and effective microbicides and vaccines accelerated. There is no scope for complacency.

Over the past couple of years, the anti-HIV microbicides research has finally given positive outcomes. This news is particularly encouraging to health advocates because microbicides research had a series of disappointing news in the past decade with different microbicide-candidate-products under research showing no positive anti-HIV effect in human trials. But now with positive research outcomes on microbicides and HIV vaccines (Thai trials 2009), we must push for faster and ethical research so that these new prevention technologies become available to most at risk populations of key affected women and girls.

The development of microbicides is seen as a key to empowering women to protect themselves from HIV. Women are biologically more vulnerable to the transmission of STIs and many cultural and economic factors compound this vulnerability.

Millions of women live in societies that permit them no role in sexual decision-making, that condone male infidelity and assign the burden of shame and stigma associated with infectious diseases to women. Existing preventative strategies have largely failed to address this vulnerability, focusing on abstinence, mutual monogamy and male condom use, none of which are easily controlled by women.

Vaginal microbicides are also likely to fail until men understand and respect the need for women to protect themselves against HIV and other STIs. Not only do women need preventative options that they can choose to use freely but the gender inequalities that make it harder for women to insist on safer sex must be addressed alongside.

RECTAL MICROBICIDES: In countries such as India there is not even basic science happening on rectal microbicides despite alarming HIV infection rates in MSM and transgender populations. This is another clear area for more advocacy and action where research reflects the needs of the communities.